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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Thursday, July 19, 2012

The Oregon Lottery: Far from enough, but at least they are doing something

On June 22, 2012, the New
York Times published an article on the results of the Oregon lottery. No,
this was not your “pick 3” or “powerball”; this was a lottery to get publicly
funded health insurance. “In
Oregon, Test Case for Health Overhaul, Better Care at a Cost”, Annie Lowrey
describes the outcome of Oregon conducting, in 2008, an actual lottery for
working-age adults living in poverty to get on to Medicaid. It was not,
presumably, intended as an experiment (although certainly people knew that it
would end up being one), but rather the result of the state not having enough
money to enroll everyone in that category.

The results, after 4 years, should surprise no one. The
study “has found that gaining insurance
makes people feel healthier, happier and more financially stable,” and that
“The insured were 25 percent less likely
to have an unpaid medical bill sent to a collection agency and 40 percent less
likely to borrow money or skip paying other bills in order to cover their
medical costs.” First of all, it is obvious. Having coverage makes it
possible to go to the doctor to care for chronic disease and actually get
better, or keep it from getting worse, it means you don’t have to forgo paying
the rent or electric bill or buying food to get care, and it saves you from
bankruptcy when you do have to go to the hospital. Second of all, a similar
study was done before, the RAND Health Insurance
Experiment of the 1970s and 1980s, which followed the result of giving free
care or care with a co-pay to previously uninsured adults. A large number of publications
resulted from this study, which was led by Joseph Newhouse. A key finding was
that people with free care used more care than those who had to pay a
co-payment (and much more than those with no insurance). This included care
such as going to doctor for minor conditions (something many health care
pundits consider “inappropriate” use of care, except, of course, when they are
doing it). It also, however, included care that everyone agrees was
“appropriate” – that cured acute conditions, controlled chronic disease, and
prevented death.

Newhouse, along with Amy Finkelstein (“… the most recent winner of the John Bates Clark Medal, an economic
prize considered second only to the Nobel”), was the evaluator of the
Oregon Study; their high credentials lend credibility to results which would
only have been incredible if they had gone the other way. Another obvious
finding is that the insured spent more on health care than those who were
uninsured. This finding, Ms. Lowrey says, was “dashing [to] some hopes of preventive-medicine advocates who have
argued that coverage can save money — by keeping people out of emergency rooms,
for instance.” Well, I’m sorry that getting care didn’t cost less than not
getting care, but it is very hard to argue that this is a credible argument
against helping people get health care. Besides, neither the total amount spent
by the newly insured, nor the difference was very much: “…the newly insured spent an
average of $778 a year, or 25 percent, more on health care than those who did
not win insurance.”

Note the phrase “win
insurance.” Not “had insurance.” It was a lottery, remember. The winners
did a lot better than those folks who didn’t win. It’s kind of like being the
third-world kid who is lucky enough to “win” by living in the “right” village
where a “mission” trip comes to do surgery for your congenital anomaly. The
Oregon lottery, even if it wasn’t intended as research, does illustrate why
some people fear participating in research. They think that they will be
“experimented on” and that they may not get treatment that will work and save
them. It is often had to explain to people that we, the researchers, don’t know what works, what will save them,
until after we have done the study.
The legacy of the Tuskegee syphilis study continues to poison the well in terms
of recruiting study participants, especially among minority groups like
African-Americans. In Tuskegee, poor black men in the South were followed for
four decades to determine the “natural history” of syphilis. Most outrageous,
of course, was that the study continued for decades after effective treatment
for syphilis, penicillin, was available, and they were not treated.

The Oregon health lottery is, in many ways, not like
Tuskegee. It selected people randomly, through a lottery, not targeting any
particular racial group. Of course, by its nature, it targeted poor people –
working age adults who did not have health insurance. One can imagine Tuskegee
researchers saying that they weren’t really racist, that if they wanted to
study the natural history of syphilis they had to study the population that had
it – poor black men in the South. Of course, it was racist.

The most important similarity between Tuskegee and Oregon is
that we withheld treatment that we knew would work in both. The previous work
done by the RAND Health Insurance Experiment (HIE) proved what was obvious even
before – that having health coverage would improve people’s health. The Times notes that many of the Oregon
winners “…said that Medicaid had made a
significant — even transformative — difference in their lives.” It would
have made the same difference in the lives of the lottery losers. Of course,
this is the nature of a lottery; the winners do better than the losers. But
this is a lottery about people’s lives and health.

I realize that what I have written might be seen as an attack
on Oregon, saying that it did something bad. Quite the contrary; at least
Oregon, for the second time in the last 30 years, has made an effort to do what
it could to help as many uninsured poor adults as it could, and did it in a
reasonably fair way, by a lottery. Compared to most states, certainly including
my own, Kansas, it is an admirable effort that has transformed the lives of
many people that the rest of our states seem to not care about. But it is
beyond the time for such experiments; the results are in. It is time to cover
everyone. It is time to go beyond what an Affordable Care Act rescued by the
Supreme Court will provide. It is time to expand Medicare to everyone.